How should we stage breast cancer?
FOOD FOR THOUGHT • Joanna Wolska
In the UK, over 11,000 women die annually from breast cancer, making it the 4th most common cause of cancer death in the UK. With about 840 breast cancer cases annually, the Edinburgh Breast Unit is the largest specialist breast unit within Scotland.
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Investigating the presence and extent of potential metastatic spread is crucial at the time of diagnosis and helps determine future treatment options. The commonly used guidelines, including National Institute for Health and Care Excellence, Royal College of Radiologists and National Comprehensive Cancer Network, are ambiguous and do not present clear outline of the recommended staging protocol. The Scottish Intercollegiate Guidelines do not provide any recommendations on diagnosis, staging, follow up or management of patients with metastatic disease.
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​It is hard to believe that there is so little guidance as to when and how to stage one of the most common cancers in the world. Therefore, as part of my Student Selected Component 5a, I decided to identify new criteria for breast cancer staging and assess their implementation feasibility in the Edinburgh Breast Unit. We hypothesized that revised criteria (breast cancer stage of T3 or above, N2 or above, HER2 positive status, triple negative phenotype, inflammatory breast cancer and symptomatic patients) would significantly reduce the number of patients undergoing staging, whilst still detecting the majority of cases with metastatic disease at presentation.
Data of 484 patients diagnosed between 2015 and 2017 was retrieved from the South East Scotland Cancer Network service which is a retrospectively collected dataset covering NHS Scotland health boards. My audit confirmed low numbers of patients presenting with metastatic disease annually, and the new criteria in combination with evaluation of referable symptoms would identify the majority (99%) of patients with metastatic disease at presentation. This project also demonstrated that there is a scope for improvement regarding specific criteria for patients with triple negative phenotype or family history of breast cancer.
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The recommended guidelines for breast cancer staging are variable and very unclear, and the detection rates of metastatic disease using the current criteria are extremely low. It is difficult to come to terms with a diagnosis of breast cancer. Most patients feel confused, angry, guilty or shocked when they are diagnosed. Everyone reacts in their own way. Therefore, it is our responsibility as future doctors to assist them in their journey by setting out consistent and efficient guidelines for breast cancer staging.
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